David P. Rapaport, MD, F.A.C.S
905 Fifth Avenue, New York, NY 10021
Phone: (212) 249-9955 Fax: (212) 249-0439
SPOUSE OR PARTNER CONTACT INFORMATION [If applicable]
EMERGENCY CONTACT INFORMATION:
Height: feet* feet inches* inches
Weight: feet* lbs
PERSONAL MEDICAL HISTORY:
Assignment & Release
I First Name* Last Name* assign directly to Dr. David P. Rapaport and associates all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges incurred. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.
David P. Rapaport, M.D., & associates feels strongly about his patients' privacy as well as his practices' right to control its public image and privacy. David Rapaport, M.D., and associates agrees not to be paid for selling patients lists or protected health information to any third party for the purpose of marketing directly to his patients. In consideration for treatment and the above noted Patient protection, Patient agrees to refrain from directly or indirectly publishing or airing commentary upon the Physician; and they will use all reasonable efforts to prevent any member of their family from engaging in such activity. David Rapaport, M.D., and associates has the right to equitable relief to prevent the initiation or continuation of publishing or airing of commentary upon his practice, expertise and/or treatment. Both Physician and Patient will work to prevent the publishing or airing of commentary about the other party from being accessed via internet, blogs or other electronic, print or broadcast media without prior written consent. Finally, this Agreement shall be in force and enforceable for a period of five years from Physician's last date of service to Patient. Patient has been given the opportunity to ask questions and receive adequate answers to his/her satisfaction. Refund policy: Please note that our office does not provide refunds on any services rendered. All sales, including deposits for treatments, are final. Skincare products may be exchanged if damaged or unused within 14 days of purchase.
Credit Card Authorization Form
Life happens! We understand that a situation may arise that could force you to cancel or postpone your appointment. We would like to kindly remind you of office policies & procedures regarding the cancellation, no show, scheduling and/or rescheduling of all appointments. Please note this includes complimentary appointments.
A valid credit card is required at the time of scheduling your appointment. This card is to hold your appointment only and will not be charged until the day of your consultation. If you arrive more than 15 minutes late to your appointment, we cannot guarantee that you will be seen by the provider. Unfortunately, this pushes back the entire schedule and it is unfair for the patients who are after you.
I blanks* authorize Coolspa, David P. Rapaport, M.D., F.A.C.S., and any of its Associates/Providers to keep my credit card information on file and to charge this card for any outstanding balances.Time allocated for an appointment is reserved especially for you. We do understand that sometimes schedule adjustments are necessary; therefore, we respectfully request at least 48 hours' notice and/or 2 business days for cancellations or to make changes to your appointment.In the event that we do not receive the required 48 hours' notice and/or 2 business days to reschedule, cancel, or "no-show" to your appointment, your credit card on file will be charged a $300.00 penalty fee and/or forfeit their $500 deposit. Business days include Mondays through Fridays. Monday and Saturday appointments must be cancelled by Thursday.As you can appreciate, there is a tremendous amount of work performed by Coolspa, David P. Rapaport, M.D., F.A.C.S., and any of its Associates/Providers in both front and back office to schedule your appointment. Please therefore be advised that it is the policy of the office to charge the non-refundable $300.00 deposit when a patient chooses to secure an appointment or treatment day. The $300.00 scheduling deposit is non-refundable.
Amount to Charge: $300
I authorize Coolspa, David P. Rapaport, M.D., F.A.C.S., and any of its Associates/Providers to charge the amount listed above to the credit card provided. Initials: please initial*
All reservations for office procedures require a credit card on file. Deposits and payments for procedures are non-refundable. Initials: Please Initial*